How a Liver Unit Failed

For at least four years, UCI Medical Center officials and employees knew that liver transplant candidates were dying while the program turned down a huge portion of donated organs it was offered.

But the program continued to enroll patients, market its services and try piecemeal fixes that ultimately failed, according to interviews and documents obtained by The Times.

Administrators resisted closing the transplant center until Thursday, hours after the federal government revoked its certification. They believed that the program, the only one in Orange County, was important to the region and to the reputation of the hospital, which is in Orange.

"If we look back at it now, it's easy to see that plans put in place turned out not to be successful," UC Irvine Chancellor Dr. Michael V. Drake said Friday. "It's harder to see that in the present than it is to see it in hindsight."

The long, slow crash had begun by 2001.

That year, 35 people died while waiting for new livers -- more than double the previous year. Just 15 received transplants.

Alarmed, Dr. John Hoefs went looking for answers. He discovered that the problem went beyond a shortage of livers. Even when seemingly suitable livers were offered for patients, the transplant program was turning the organs down.

Hoefs, a UCI liver specialist who is not a transplant surgeon, said he relayed his concerns to hospital administrators. He said he felt confident that the hospital was responding.

Even so, he steered some of his sickest transplant candidates to other hospitals to increase their odds of getting a liver.

"I don't have that kind of loyalty that I would ever sacrifice my patients' best interest," he said.

It didn't take long before doctors, nurses and other employees also grasped that the transplant program was in deep trouble -- mainly because it didn't have enough surgeons to operate, according to interviews with hospital leaders, staffers and former staffers.

"Everybody became aware," Hoefs said. "Suddenly, we were dealing with a problem."

The hospital faced a dilemma: Publicly revealing the problems could lead to the program's demise, but keeping patients on the waiting list could prove fatal.

Administrators took the risk that they could make things better.

They tried to hire new surgeons. They crafted a marketing campaign to attract new patients. They begged regulators for more time. They sidelined people who complained and looked past doctors' egos and what Hoefs described as their "peculiar behaviors." They hung on by persuading two doctors from UC San Diego to work part-time.

All the while, they kept adding patients to the waiting list -- until this week.

In pulling the program's certification Thursday, the U.S. Centers for Medicare and Medicaid Services said that not enough transplants were being performed to maintain proficiency. The few patients who received new livers were dying at an unacceptable rate.

Dr. Ralph Cygan, UCI Medical Center's chief executive, insisted that the university placed the patients' best interests first. But he acknowledged that he would have acted differently had he known the problems would take so long to fix. "I would have insisted that we would have closed the program until we were in a better position," he said.

But now, families of patients who died are left to wonder whether those lives might have been saved.

Audrey Degenhardt said her husband, Geoffrey, had been told that the greatest obstacle to his receiving a transplant was a lack of donated livers in Southern California.

Still, she said, "he was so optimistic. He always thought he was going to get one."

Geoffrey Degenhardt, a warehouse manager who had hepatitis C, never left home without the pager the hospital had given him.

The pager never beeped. He died April 3, 2004, at the age of 51.

"Maybe it's a good thing he's not here to see this," Audrey Degenhardt said. "How insane is that, to turn down livers? How many people have died because of them not having a doctor on duty?"

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When UCI Medical Center opened its liver transplant program in 1993, the campus saw it as having great potential.

The surgery was becoming increasingly common, and Orange County was an ideal market, with a large population of patients with hepatitis C, a leading cause of liver failure.

At first, the program was run as a satellite to the UCLA liver transplant program, with Dr. David Imagawa in charge. Surgeons performed 105 transplants in the first seven years, surpassing the federal minimum of 12 per year.

In early 2000, the program had three full-time surgeons. But one soon left, and the following year, Imagawa suffered a heart attack. He returned to work but stopped performing transplants.

That left Dr. Sean Cao as the only full-time liver transplant surgeon. Cao had joined the program in 2000 and quickly alienated many staffers, according to people who had worked with him.

Many were deeply loyal to Imagawa, who was struggling to retain some control of the program. The two surgeons clashed, and Imagawa was eventually moved to a separate building, said Lorrie Gibson, who coordinated transplants but has subsequently retired.

Cao was promoted to liver transplant director. Resentment against him grew, said former staffers.

Most worrisome was that he appeared focused on liver and pancreas surgeries that could be scheduled -- and not transplants.

"He was building a practice in other types of liver surgery," said Dr. Jorge Ortiz, a transplant surgeon who overlapped with Cao at UCI for most of 2000.

Cao did not return phone calls seeking comment.

Cygan, the hospital's chief executive, said he and others worked with Cao to "develop him as a physician leader." They guaranteed him a salary so he wouldn't feel the need to perform so many elective procedures instead of transplants.

On Friday, Cygan acknowledged that "we may have stuck with Dr. Cao, in retrospect, a little longer than we should have."

After Imagawa stopped performing transplants in 2001, staff members at OneLegacy, the local agency in charge of allocating donated organs, noticed that UCI was turning down an increasing share of organ offers, said Thomas Mone, the CEO.

Many of the refused organs were accepted by other medical centers and transplanted into their patients. In 2002, UCI received 165 liver offers from OneLegacy. Just six were accepted. Two other transplants were done that year, but those livers came from outside the Los Angeles region.

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UCI was desperate to recruit new surgeons.

In July 2002, the hospital hired Dr. Anthony Savo, a transplant surgeon. But three months later, the administration moved him to general surgery after he clashed with Cao, according to Gibson.

She and the other transplant coordinators rushed to Savo's defense, she said, but the administrators would not heed their complaints about Cao.

Savo, who finished his two-year contract and left UCI, declined to comment.

Tensions escalated to the point that the surgery department chairman called a special meeting to reduce anxiety, according to a memo drafted by the transplant coordinators in October 2002 but never sent.

UCI continued to depend on Cao.

In November of that year, the hospital brought in two outside transplant surgeons to review the program and they identified a number of problems, including a high rate of organ refusals.

As a result, the transplant program changed the way it handled organ offers. Until then, the transplant coordinator on duty would receive the call, collect information about the organ and share it with the surgeon, who would decide whether to harvest it. Now, the calls would go directly to the surgeon.

The change excluded coordinators from the process, leaving them feeling jilted. It also meant that Cao could refuse organs without anyone inside the program immediately realizing it.

The refusals continued apace, even as the United Network for Organ Sharing, a national oversight group, conducted a routine audit in 2003.

Just eight transplants were performed that year, the same as in 2002.

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By early 2004, state health officials had seen enough to know that the program fell well below minimum standards for operating on patients on Medi-Cal, the state's health insurance program for the poor.

The hospital was not performing at least 18 liver transplants a year--the state requirement for maintaining proficiency, which is stricter than the federal standard.

In a Feb. 11, 2004, letter to the state Department of Health Services, Cygan wrote that the hospital was having trouble attracting liver transplant surgeons. One, from Philadelphia, had turned down a recent job offer.

Despite the doctor shortage -- and the fact that UCI was transplanting livers at less than one-third the rate of other hospitals in the region -- the medical center was still working to recruit patients for the waiting list.

The hospital planned to host dinners for physicians in the hope that they would refer more patients, Cygan wrote, and to put up a marquee commemorating upcoming National Organ Tissue and Donor Awareness Month.

Unmoved by UCI's response, the state pulled its certification for the program that May, meaning that it would no longer pay for Medi-Cal patients' surgeries.

By then, Cao was preparing to leave UCI. He instructed transplant coordinators to transfer patients to waiting lists at other hospitals, Gibson said.

"The sicker ones were the priority to move -- to get them listed at places where they had a better chance of getting a transplant," she said.

She referred Andrea Razetto, whose liver was ravaged by hepatitis C, to Rush University Medical Center in Chicago, where she quickly received a transplant.

For six years, she had withered on the list at UCI. "Every time I asked, they said, 'No, we don't have a liver,' " said Razetto, now 63. She has since sued UCI for damages, and the case is pending.

Few patients were moved, and new ones were still being added.

Since Cao left in July 2004, to go into private practice in Fountain Valley doing liver and pancreas surgeries -- but not transplants -- UCI has relied on Drs. Marquis Hart and Ajai Khanna. Both work full time at UC San Diego, 90 miles away.

The hospital has continued to refuse livers more than any other transplant center in the region. Just four of the 129 offers made to UCI by OneLegacy were accepted this year.

When the program was closed Thursday, 106 patients remained on the waiting list.

The decision also put a surgeon at the University of Pittsburgh in a bind. Dr. Michael E. De Vera had just accepted an offer to head the liver transplant program full-time.

"That's now not happening," Drake said Friday.

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Even before the shutdown, some people who knew the program's history tried to limit the damage.

Carol Craig did not work in the transplant center but taught UCI patients about hepatitis C until 2004, working directly with Hoefs.

She remembers the transplant program as a cold place, where patients were sometimes left in tears.

Now she works elsewhere as an advocate for hepatitis patients, who turn to her for recommendations on transplant centers.

Two weeks ago, Craig organized a bus trip for 31 patients from Orange County to see the transplant program at USC.

"It was wonderful -- gosh," she said.

Before taking gravely ill patients all the way to Los Angeles, Craig thought hard. She asked herself: "Would I go to UCI if I had choices?"